The findings of the kitchen inspection, conducted 3/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/12/24, conducted 05/13/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the secod revisit to the kitchen inspection of 03/12/24, conducted 07/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 03/12/24, conducted 09/19/24 through 09/20/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility kitchen was completed on 03/12/24 from 11 am through 3:30 pm and the following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Floors and walls under dish machine;

* Floors throughout kitchen;

* Walk in cooler floors/corners/edges/walls;

* Walls throughout kitchen;

* Fans and metal cages of fans;

* Reach in coolers and freezers;

* Open shelving throughout kitchen;

* Interior and exterior of microwave;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Range top, grill top;

* Metal shelves storing pots/pans/dishes;

* Knobs of steam table;

* Steam table wells;

* Cabinet with plate warmer;

* Industrial can opener and housing;

* Steamer with scale build up and dirty on interior and exterior;

* Industrial mixer;

* Door thresholds with food debris/splatter;

* Interiors and exteriors of stainless steal drawers;

* Go racks stored in walk in;

* Metal racks in Walk in cooler;

* Freezer fan cages;

* Outside and handles of trash cans;

* Small appliances (blender/robot coupe);

* Ice scoop holder;

* Window seal and screens: and

* Kitchen drains.

b. The following areas were in need of repair:

* Hole in wall under prep counter where cutting boards stored;

* Three compartment sink faucet with leak;

* Spring loaded sprayer broken and sitting at bottom of sink;

* Caulking behind hand washing sink and ware washing area with black mold like substance;

* Pipe from wall next to large fan with gap needing sealed; and

* Sprinkler in walk in cooler leaking.

c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination.

d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple pans/utensils with damage and wear needing to be replaced.

e. Multiple food items found in walk in cooler without proper labels and/or dates as required. Items found open or not sealed appropriately to protect from potential contamination.  

f. Multiple food packages were found open in dry storage.

g. Shell eggs and liquid eggs stored over box of "fresh greens". Cardboard box of food items with visible wet debris. Staff stating sprinkler in walk in leaking.

h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them.

i. Large meat roast observed being thawed under cold running water upon entry to kitchen. These roasts were then observed at 12:25 on a large pan on a go rack in the main kitchen. Again at 1:35pm these meat roasts were still observed out of refrigeration on the pan on the go rack.  

j. Cardboard and recyclables were not stored appropriately and were not separate from food preparation areas. Staff 2 indicated they did not have a good space to store them until taking out to garbage area.

k. At 12:05 pm, a staff member entered into kitchen and got ice out of ice machine. The staff member did not wash hands and did not have their hair restrained as required.

Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 3:00 pm, surveyor reviewed above areas with staff 1 (Administrator), who acknowledged the findings.

-DSC trained on Menu Manager by Dining Pro-Temp Specialist. Menu Manager ensures three daily nutritious, palatable meals with sncaks available severn days a week.  Snacks have been scheduled to be provided at 10:00 am, 3:00 pm & 6:00pm for Claire Bridge.

-DSC conducted Modified special diets training on 4/2/24.

-DSC will conduct Menu Chat 2x a month (Bi-Weekly) with all residents encouraged to attend in support of developing menus.

DSC will have menus completed each Saturday for the following week. Week at a glance will be posted in the dining room allowing residents to view.

DSC & Pro-Temp have menu in community matching menu on Community Website.

Should a change be made to an existing menu, the DSC and or Cook on shift will update menu slips prior to the residents arrival to the dining room for the specified meal having changes. Dining Servers will have a pre-shift meeting conducted prior to each meal. Any changes made to the menu will be discussed during pre-shift ensuring servers know what is being served. A sample plate for both AL and Clare Bridge will be provided for residents to see the presentation of entrees being offered.

March 22, 2024- Restaurant Exhaust completed cleaning of  all kitchen surfaces including: ceilings, kitchen equipt., tables, light lenses. All line equipment under the hood: Ovens, stoves, flattop griddles, etc..All Light lenses and bulb covers (21), and all kitchen tables, shelves, carts and appliance surfaces.

April 2, 2024- Summit Cleaning and Restoration will be completing  

oDeep Cleaning of all FRP Wall Panels

oDeep Cleaning of all Tiled Flooring in Kitchen, Dish Room, & Hallway

oMildew Removal & Treatment around Dishpit

oDeep Cleaning of all Tile Flooring in Kitchen, Dish Room, & Freezer.

-DSC implemented cleaning schedule for all servers and cooks along with cleaning schedule and expectations from Brookdale Cleaning Schedule. Expectations will posted on bulletin board for all to see and know the expectations on a daily basis. DSC responsible for reviewing task sheets and following up on completed tasks to ensure tasks completed correctly and efficiently.

Task lists include but not limited to:

* Interior and exterior of microwave;

* Interior and exterior of convection

ovens;

* Exterior and interior of steamer;

* Range top, grill top;

* Metal shelves storing pots/pans/dishes;

* Knobs of steam table;

Steam table wells;

* Industrial can opener and housing;

* Cleaning of Steamer removing scale build up

on interior and exterior will be completed after each meal service;

* Cleaning of Industrial mixer after each use;

* Cleaning of Door thresholds with any food

debris/splatter;

* Interiors and exteriors of stainless steal

drawers;

*Pressure washing weekly and daily Cleaning of trash cans on the outside including handles

* Freezer and fan cages are working and are checked every 4 hours.

* Window seals cleaned and screens pressure washed

* Ice scooper container on task list to be washed each day along with only on scope placed in container.

*Open shelving holding dishes will have doors installed protecting dishes from dust and food debris.

Cabinet with plate warmer has been cleaned and will have door installed closing up the open area. A vent will be installed allowing for proper airflow.

* Hole in wall under prep counter where

cutting boards stored repaired by Maintenance Director. Metal plate placed on back of wall preventing cutting boards from hitting wall resulting in holes.

* Roto Rooter has ordered drains for three compartment sink Roto Rooter will also be capping off overflow holes;

Maintenance Director will be replacing faucet ring stopping leak.

* Spring loaded sprayer replaced with new sprayer allowing sprayer to dangle above the bottom of the sink;

* Maintenance Director will be completing new Caulking behind hand washing sink upon completion of Summit wall and floor cleaning.

*Ware washing area with black mold like substance will be cleaned and treated along with new caulking an selant applied. Summit Restortation will complete cleaning and Maintenance Director will complete new caulking and sealant.

* Pipe from wall next to large fan with

gap will be filled with Fire Caulking by the Maintenance Director

* Sprinkler in walk in cooler leaking will be repaired by Harvey & Price on 4/3/24.

*New containers ordered with holder for Scoops/spoons for bulk food containers to prevent handles touching food and/or

surfaces.

*Coffee filters stored in a covered container to prevent potential contamination.

*Cutting boards have all been replaced with new cutting boards.

*Replacement Pans/utensils ordered on 3/31/2024.

*DSC and Pro-Temp completed trainings with cooks and servers on the proper labeling protocols.

* DSC ordered new food containers to store opened items ensuring and and all open items are sealed appropriately to protect from potential contamination.

* DSC and Pro-Temp completed training on FIFO order along with posting Food Storage Chart on front of fridge door.

* DSC ordered new storage containers with scoop holders to house dry ingredients stored in dry storage.

* Walk-in fridge has been organized by DSC and Pro-Temp following Crandall guidelines.

Shell eggs and liquid eggs along with all dairy items are stored in the back of the walk-in fridge (coldest section) from top shelf to bottom shelf having no non-dairy items stored above or below dairy products.

*DSC and Pro-Temp have reorganized all cooking/prep dishes which are now stored inverted as required preventing any debris build up.

*DSC and Pro-Temp completed training on proper thawing of frozen meat products on 4/2/24.

*Cardboard broken down and taken out to recycling thoughtout the day rather than piling up in the back of the kitchen. This task is assigned and is being completed by the Dish Aid on shift with the DSC following up to ensure this task is being complete and not cardboard is piling up.

* ALL Associates have received specific instruction and training on applying hair nets upon entering the kitchen and washing hands immediately after placing hair net on head.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the facility ALF kitchen was completed on 05/13/24 from 10:15 am through 12:45 pm and the following was identified:  

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Ceiling vent near prep area

* Floors throughout kitchen;

* Walls throughout kitchen;

* Fans and metal cages of fan by serving area;

* Open shelving throughout kitchen;

* Interior and exterior of microwave;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Range top, grill top;

* Metal shelves storing pots/pans/dishes;

* Steam table wells;

* Industrial can opener housing;

* Steamer interior and exterior;

* Industrial mixer;

* Door thresholds with food debris/splatter;

* Interiors and exteriors of stainless steel drawers;

* Window seal and screens; and

* Kitchen drains.

b. The following areas were in need of repair:

* Areas by electrical conduit/pipes with gaps.

c. Scoops were observed in bulk food containers with handles touching food surfaces.

d. Multiple food items were observed in walk-in cooler without proper labels and/or dates as required. Container of cut tomatoes was found stored in walk-in cooler. It was dated 04/30/24 multiple days past seven days that's allowed per rule.

e. Multiple food packages were found opened in dry storage without open dates.

f. Thawing meats were not stored correctly according to appropriate cook to temps to prevent potential cross contamination. Whole pork roasts were noted to be stored directly under ground meat products.

Staff 2 (Dining Service Coordinator) toured kitchen areas and acknowledged areas in need of correction.  At approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

- Floors throughout the kitchen cleaned and added to daily checklist

-Walls throughout the kitchen cleaned and added to daily checklist

Open shelving throughout kitchen cleaned and added to daily checklist

Interior and exterior of microwave cleaned and added to daily checklist

Interior and exterior of convection ovens cleaned and added to daily checklist

Exterior and interior of steamer cleaned and added to daily checklist

Range top, grill top cleaned and added to daily checklist

Metal shelves storing pots/pans/dishes cleaned and added to daily checklist

Steam table wells cleaned and added to daily checklist

Industrial can opener housing cleaned and added to weekly checklist

Industrial mixer cleaned and added to daily checklist

Door threshholds with food debris/splatter cleaned and added to daily checklist

Interiors and exteriors of stainless steel drawers cleaned and added to weekly checklist

Window seal and screens cleaned and added to weekly checklist

Kitchen Drains cleaned and added to weekly checklist

-Areas with electrical conduit pipes that have gaps will be filled in by Maintenance staff by 5/31/24

Proper labeling of all food items will be done by kitchen staff and be monitored daily

Dry storage items that are opened will be labeled with open dates and monitored daily

Storage scoops will be put up and not sitting in food bins and monitored daily

Thawing meats will be stored according to the food storage heirarchy and monitored daily

**Staff will be retrained on the following:

-Proper storage of scoops in bulk food containers

-Proper labeling and storage of food in both dry storage and in refrigerators and freezers

-Food storage heirarchy

All Items will be monitoried by the ED and Dining Services Manager.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the facility ALF kitchen was completed on 07/25/24 from 12:00 pm through 1:45 pm and the following was identified:  

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Floors throughout kitchen;

* Fans and cages in Walk in cooler;

* Floors in walk in cooler;

* Open shelving throughout kitchen;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Metal shelves storing pots/pans/dishes;

* Baking "go" racks;

* Number 10 can storage racks; and

* Kitchen drains.

b. Scoops were observed in bulk food containers with handles touching food surfaces.

c. Box of frozen hamburger patties were found open and uncovered in the walk in cooler.

On 07/25/24, Staff 2 (Dining Service Coordinator) toured the kitchen with the surveyor and acknowledged the findings.  At approximately 1:30 pm, the surveyor reviewed the above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

1. Executive Director and Dining Services coordinator will ensure plan of correction is followed and compliance maintained.

2.  Executive Director and Dining Serivces Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on kitchen cleanliness checklists, and inservice staff on proper food storage.

3. Areas of correction wil be audited weekly and as needed

4. Eecutive Director and dining Services Coordinator are responsible for monitoring and ongoing compliance.

Based on record review and interview, it was determined the facility failed to ensure 4 of 9 sampled staff (#2, 3, 4, and 5) who prepared food had active food handlers certificates. Findings include, but are not limited to:

On 03/12/24 employee records were requested and reviewed to ensure staff had active food handlers cards on file. Staff 2 (Dining Services Coordinator) and Staff 3 (Cook) whose food cards could not be located.  In addition, Staff 4 and Staff 5 (Resident Assistants) did not have active food handlers cards. Staff 1 (Executive Director) acknowledged the need for food handler cards for these individuals.

C370:

DSC has completed Serve Safe testing and has been issued her Serve Safe Certification as of 4.1.24. Staff 3 (cook)- will have Food Handler card by 4.3.24. Additional Cook will have food handler card by 4.4.24.

Business Office Coordinator has copies of all associates food handlers cards on file in Business Office  

Based on interview and observation, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 240.

Refer to C 240.

Based on interview, observation, and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.

1. Food spills,splatters,loose food, trash debris, and dust/dirt floors throughout kitchen, including floors in walk in cooler and ares under open shelving will be swept and mopped twice daily. Baking "go" racks, Number 10 storage racks, and metal shelves storing pots/pans/dishes will be pressured washed by 8/14/2024. Interior and exterior of convection ovens will be cleaned by 8/12/2024. Exterior and interior of steamer has been cleaned as of 8/4/2024. Kitchen drains have been cleaned as of 8/4/2024. Fans and cages in walk in will be cleaned as 8/12/2024. Scoops for bulk food storage have been removed from bins and signage posted for staff reference on preventing handles from touching food as of 8/8/2024.

2.  Executive Director and Dining Services Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on daily kitchen cleanliness checklists, use and storage of bulk food scoops. and inservice staff on proper food storage.

3. Areas of correction wil be audited weekly and as needed.

4. Executive Director and Dining Services Coordinator are responsible for monitoring and ongoing compliance.